Healthcare Provider Details

I. General information

NPI: 1457784381
Provider Name (Legal Business Name): MARC TODD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 DRAKE CT
PETALUMA CA
94954-2365
US

IV. Provider business mailing address

1717 DRAKE CT
PETALUMA CA
94954-2365
US

V. Phone/Fax

Practice location:
  • Phone: 714-404-2734
  • Fax:
Mailing address:
  • Phone: 714-404-2734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number39876
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number39876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: